Provider Demographics
NPI:1366500209
Name:PORTER, SAMUEL JAIME (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JAIME
Last Name:PORTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:321 N LARCHMONT BLVD
Mailing Address - Street 2:SUITE 618
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3025
Mailing Address - Country:US
Mailing Address - Phone:323-469-7133
Mailing Address - Fax:323-469-7150
Practice Address - Street 1:321 N LARCHMONT BLVD
Practice Address - Street 2:SUITE 618
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-6406
Practice Address - Country:US
Practice Address - Phone:323-469-7133
Practice Address - Fax:323-469-7150
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22916207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A229160Medicaid
A23302Medicare UPIN
A22916Medicare ID - Type Unspecified